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All about the public option

From NBC's Mark MurrayWhen then-candidate Barack Obama first unveiled his health-care plan, on May 29, 2007, his 3,600-word speech didn't contain the words "public option" in it. There wasn't a single mention of it (although an accompanying fact sheet did refer to a "new public plan" that would be open to individuals without access to other coverage).

The words "public option" or "public plan" also didn't appear in Obama's convention speech in Denver, nor in his victory address at Grant Park in Chicago.

All of this is ironic given that the debate over health care now -- especially now that Democrats, and perhaps one or two Republican senators, are the key players in it -- has become all about the public option.

Congressional liberals are demanding it. "A bill without a strong public option will not pass the House," House Speaker Nancy Pelosi said in a statement yesterday. "Eliminating the public option would be a major victory for the insurance companies who have rationed care, increased premiums and denied coverage."

Added the House Progressive Caucus: "Any bill that does not provide, at a minimum, a public option built on the Medicare provider system and with reimbursement based on Medicare rates-not negotiated rates-is unacceptable."

On the other hand, centrist Blue Dog House members, as well as moderate Democratic senators (especially those from the South and Mountain West), are opposed to public option.

All of which has put Obama in the middle of this debate -- a comfortable position during presidential elections, but not so much during the legislative sausage-making process.

Obama has said he prefers a public option, a government-run insurance program like Medicare, as a way to put pressure on private insurers to keep their costs and prices down. But he also consistently hasn't made it a non-negotiable demand. "He believes deeply in competition and choice within the insurance system," White House senior adviser David Axelrod told NBC's Chuck Todd earlier this week. "He believes the public plan -- the public option is one way to do that within the insurance exchange."

How did we get to this point, where the debate became all about the public option?

According to Yale political science professor Jacob Hacker, who is a public-option proponent and actually helped create the idea, progressives and reform advocates have seen it over the past few years as a mechanism to ensure accountability from a system centered on private insurance, and Obama, Hillary Clinton, and John Edwards all included it in their health-care plans. But what also elevated the issue, Hacker says, was the opposition from the right, which then only stiffened the resolve from liberals.

There's a third reason: The back-and-forth over the public option is much easier for the media to understand than the debate over other health policy minutiae.

So where do we go from here? David Gregory reports that the president is preparing to tell liberals in Congress that it's time to be good soldiers. "While he is expected to stand behind the idea of a public option, he is also expected to stress that it can't be MORE important than some of the other reforms that are possible this year, including insurance reform that would guarantee coverage for individuals with pre-existing conditions," Gregory says. "He'll argue that as with Social Security, Democrats should start with an achievable foundation and build on it from there."

And one of the compromise ideas out there -- supported by Maine GOP Sen. Olympia Snowe -- is a trigger, which would kick in a public option if there's proof there isn't enough competition from private insurers.

While Obama didn't say the words "public option" in his health-care speech in 2007, he did say this: "The very first promise I made on this campaign was that as president, I will sign a universal health care plan into law by the end of my first term in office."

That's the promise he made. Yet whether or not he gets to fulfill that promise could be determined by what the eventual legislation contains -- and how it's received from members of his own party.